The trial and sentencing of 20 medical professionals in Bahrain in the past two weeks has again turned the spotlight on the small Gulf Kingdom’s unfinished ‘Arab Spring’ and the repressive methods used to contain it.

The sentencing of doctors, nurses and paramedics who treated injured protesters to imprisonment of five to fifteen years has grabbed the world’s attention in a way that trials of others involved in protests in Bahrain – including human rights activists, bloggers, and teachers – has not. Imprisoning doctors, it seems, is a step too far – a signal taken on board by the government, which announced last week that the 20 will be retried in a civilian court.

The strong international reaction that the case has provoked focuses attention on the value placed on respect for medical neutrality in times of conflict and civil unrest.

In the wake of popular uprisings in Egypt and Tunisia, Bahrain too saw mass protests in February and March from citizens demanding constitutional change. Although initially tolerated by the regime, the protesters quickly faced a sharp crackdown, as security forces backed by tanks and helicopters drove them out of Pearl Roundabout where they had gathered. In the aftermath and over the following weeks injured protesters were taken to Bahrain’s main hospital for treatment. Medical staff gave interviews to the international media describing the casualties and the injuries that they were seeing, with some of them accusing the government of atrocities. At the same time the grounds of the hospital became a refuge and rallying point for protesters, including some medical staff.

This became a pretext for the regime to treat the hospital as a legitimate military target and on 16 March – the day after a state of emergency had been declared – security forces stormed it. Credible reports tell of security forces setting up checkpoints and stationing military officers to search and check the identity of all those entering the hospital, diverting and attacking ambulances carrying the wounded, beating medical staff, and segregating those with protest-related injuries into one ward where they were beaten. According to Human Rights Watch, this was part of “what appear[ed] to be a systematic campaign … aimed at punishing and intimidating medical professionals suspected of sympathies with protesters and hindering access to health care facilities for persons wounded by security forces”.

Over the following weeks hundreds of Bahrainis were arrested and detained for their association with the protests, including the 20 medical professionals sentenced for serious offences last month. Like other detainees, many of the medical professionals were taken by security forces in the middle of the night from their homes (and at least one from an operating theatre), were held incommunicado for several weeks, and allege they were tortured in detention to obtain false confessions. (These methods are not new: REDRESS is involved in a similar case which occurred last year prior to the unrest.) Like others detained under the emergency law, the medical professionals were tried by a military court which appears to have relied almost solely on confession evidence, did not allow them to present a proper defence, and did not investigate allegations of torture they raised.

The 20 have been convicted of offences ranging from calling for regime change, possession of unlicensed weapons, attempting to occupy a public building by force and “spreading false news” to denying patients treatment on sectarian bases and seizure of medical equipment (see here for the military public prosecutor’s version of events). The medical professionals – who were progressively released on bail between August and September and remain free pending their retrial – say that they treated anyone who arrived at the hospital during the height of the uprising, and that they are being targeted for simply doing their job.

The prosecution of medical professionals and militarisation of medical facilities in Bahrain throws into stark light the practical impact that targeting medical facilities and personnel can have in situations of civil unrest. Not only did it remove trained personnel – including senior consultants – from positions where they could provide treatment to the sick and injured, but other doctors reported that they were afraid to provide treatment to wounded protesters in case they were then arrested. Similarly, those injured in ongoing protests, or suffering injury following torture in detention, have been afraid to seek treatment from government hospitals and medical centres for fear of being reported or detained.

Protection and care of the sick and wounded is a fundamental principle recognised and developed particularly through international humanitarian law. This has led to detailed rules in the Geneva Conventions and customary international law on the protection of medical personnel, facilities, activities and transport in situations of “armed conflict”. The Geneva Conventions and their Protocols require states to respect and protect medical personnel engaged in humanitarian functions. States are prohibited from punishing any person for carrying out medical activities compatible with medical ethics, regardless of the person benefiting. They must not inflict violence, intimidation or harassment on patients, and individuals not in combat must be treated regardless of their political affiliation or other status.

A report by Physicians for Human Rights points out that rules of medical neutrality are not articulated as clearly in situations of civil unrest not amounting to “armed conflict”, such as that continuing in Bahrain (involving largely peaceful protesters, rather than an organised armed group). However it would be absurd if a State was allowed to carry out conduct against its own citizens that is specifically prohibited in the context of conflict with other states and armed groups, and international human rights law provides a firm basis for requiring adherence to such principles. In all circumstances, the International Covenant on Civil and Political Rights, the International Covenant on Economic, Social and Cultural Rights and the Convention against Torture apply to state signatories, including Bahrain. States are therefore prohibited from subjecting medical personnel or patients to arbitrary arrest, detention or any other unlawful deprivation of liberty, to torture and cruel, inhuman or degrading treatment or punishment and must respect and protect the right to life of those within their jurisdiction. States also have the obligation to recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, by which they must ensure the creation of conditions which assure to all people medical services and medical attention without discrimination, and in accordance with medical ethics. Targeting of medical professionals and facilities in order to stifle dissent, to identify and arrest peaceful protesters or to intimidate the population violates these core obligations, and facilitates (if not constitutes) violations of other rights such as the right to freedom of expression and assembly.

Despite international legal protections, attacks on medical neutrality are a serious and often underreported concern in both armed conflicts and civil unrest – as demonstrated by a recent report from the International Committee of the Red Cross (ICRC), and an article published last year in the Lancet by Leonard S Rubenstein and Melanie D Bittle. Given the central importance of the obligation to protect the wounded and sick, and the impact that targeting medical professionals can have on fundamental human rights, there are calls from humanitarian and human rights organisations for renewed focus to be given to monitoring, reporting and accountability for such attacks.

In the case of Bahrain, the government and its supporters have said that the medical professionals were targeted because they broke the law, and must be held accountable to it. The question is whether there is any evidence that they have abused their position in a way that would not be defensible under international law. There are conceivably circumstances in which medical professionals could do so – for example, by denying medical attention on discriminatory grounds, or by using hospitals as bases to launch armed attacks on civilians. The public prosecutor’s version of the facts could – in relation to some of the alleged crimes described (such as only treating Shiite patients calling for the toppling of the regime, and transporting unlicensed weapons in ambulances) – amount to such conduct, although many of the actions even as alleged amount to the provision of humanitarian assistance and the exercise of freedom of expression and assembly. In this case, however, the arbitrariness of detention, the allegations of torture and the nature of the trials conducted against the medical professionals call into question any evidence produced against them and any verdict reached.

There are hopes that an inquiry appointed by the King and headed by international law experts (Cherif Bassiouni, Philippe Kirsch QC, Sir Nigel Rodley, Dr Mahnhoush Arsanjani and Dr Badria Al-Awadhi) to examine the events in Bahrain will shed further light on what happened when it reports at the end of the month. But if the government really wants to counter the accusation that it has targeted the health professionals contrary to international law it must follow through on its commitment to provide them with a full and fair trial in civilian courts and in accordance with their fundamental rights. If, on the other hand, investigations prove the allegations of wrongful attacks on medical neutrality, those responsible should be held to account.